Current Concepts in the Intensive Care Management of Neurosurgical Patients

p. 494

GS Umamaheswara Rao

There have been some major conceptual changes in the approach to patients with both traumatic and nontraumatic cerebral injury, in recent years. These changes have their basis in a better understanding of the cerebral pathophysi­ology and availability of some recent monitors of cerebral function. Both traditional and modern therapeutic innova­tions are being subjected to extensive investigation. Evidence-based guidelines are now available for the management of traumatic brain injury. Increasing emphasis is being laid on monitoring not only intracranial pressure and cerebral perfusion pressure, but also cerebral blood flow, oxygenation and metabolism. Alternative osmotherapeutic choices are being explored. With a large pool of high quality evidence, more focused and precise therapeutic innovations are likely to emerge in near future.

Continuous peripheral nerve blocks provide site specific analgesia with least systemic effects. They could be effectively used for intraoperative anaesthesia and as well as for very effective postoperative analgesia. The intro­duction of ultrasound and peripheral nerve stimulators into clinical practice have aided us to place these catheters in close proximity to the neural bundle. The stimulating catheters have further aided us to be more accurate. This article describes the equipment and the technique involved in performing continuous peripheral nerve blocks.

Assessment of Sedation and Analgesia in Mechanically Ventilated Patients in Intensive Care Unit

p. 519

Udita Naithani, Pramila Bajaj, Sanjay Chhabra

Post traumatic stress resulting from an intensive care unit(ICU) stay may be prevented by adequate level of sedation and analgesia. Aims of the study were reviewing the current practices of sedation and analgesia in our ICU setup and to assess level of sedation and analgesia to know the requirement of sedative and analgesics in mechani­cally ventilated ICU patients. This prospective observational study was conducted on 50 consecutive mechanically ventilated patients in ICU over a period of 6 months. Patient's sedation level was assessed by Ramsay Sedation Scale (RSS = 1 : Agitated; 2,3 : Comfortable; 4,5,6 : Sedated) and pain intensity by Behavioural Pain Scale (BPS = 3 :No pain, to 16 : Maximum pain). BPS, mean arterial pressure(MAP) and heart rate(HR) were assessed before and after painful stimulus (tracheal suction). Although no patient had received sedative and analgesics, mean Ramsay score was 3.52±1.92 with 30% patients categorized as 'agitated', 12% as 'comfortable' and 58% as 'sedated' because of depressed consciousness level. Mean BPS at rest was 4.30±1.28 revealing background pain that further increased to 6.18±1.88 after painful stimulus. There was significant rise in HR (10.30%), MAP (7.56%) and BPS (40.86%) after painful stimulus, P<0.0001. The correlation between BPS and Ramsay Score was negative and significant (P< 0.01). We conclude that there should be regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level, using sedation and pain scales as a part of the total care for mechanically ventilated patients.

Comparison of the Effects of Sevoflurane, Desflurane and Totally Intravenous Anaesthesia with Propofol on Haemodynamic Variables Using Transesophageal Doppler

p. 527

Selen Osmanagaoglu, Hulya Ulusoy, Mehmet Salih Colak, Nesrin Erciyes

Sevoflurane and desflurane inhalation anaesthetics are in routine use providing more rapid recovery than pre­existing inhalation anaesthetics. We wanted to compare the effect of different anaesthetic agents on haemodynamic parameters with using transesophageal echo-Doppler in ASA I-II patients. A total of 45 American Society of Anes­thesiologists (ASA) physical status I-II patients age between 18-65 scheduled for elective major abdominal surgery were admitted to this prospective randomized study and divided into three groups. Induction of anaesthesia was provided with 1µgkg -1 fentanyl, 6-8 mgkg -1 thiopenthal and 0.1 mgkg -1 vecuronium in sevoflurane (Group S, n=15), and desflurane (Group D, n=15), and 1µgkg -1 remifentanil, 2mgkg -1 propofol, and 0.1 mgkg -1 vecuronium in totally intrave­nous anaesthesia (TIVA) group (Group T; n=15). For maintenance of anaesthesia, patients received an infusion of 0.15 µgkg -1 min remifentanil, 4-6 mgkg -1 h -1 propofol, sevoflurane 2%, or desflurane 6% at 1.0 MAC. Bispectral index (BIS) values of 40-60 were targeted during operation. After endotracheal intubation, the haemodynamic and respira­tory parameters, and BIS were recorded 5 min after the intubation (T 0 ), 30 min after the intubation (T 1 ), 60 min after the intubation (T 2 ) and before the extubation (T 3 ) with using haemodynamic monitoring (Hemosonic 100). After induction of anaesthetic agents, heart rate (HR) increased significantly in desflurane group (Group D) compared with group sevoflurane (Group S) and TIVA (Group T) groups at 5 min after the intubations, 30 min after the intubations, 60 min after the intubations and compared with group sevoflurane before the extubation. The Stroke Volume (SV) values increased significantly at the 5th minute intubation in Group S as compared to the Group D and in Group D as compared to the Group T. Compared with Group D, maximum acceleration (Acc) increased significanly in Group T before extubation. The BIS values were significantly lower in the Groups S and D at all the time intervals as com­pared to the Group T. Although a significant increase in HR and no significant decrease in Acc were noted in the desflurane group, sevoflurane and desflurane provided similar cardiovascular effects in the present study. The BIS values were significantly lower in the sevoflurane and desflurane groups compared with the TIVA.

Diffusion of lidocaine across the endotracheal tube (ETT) cuff helps in smooth emergence of patients from general anaesthesia by preventing ETT-induced cough to occur. Buffering enhances the rate of diffusion from ETT cuff. The aim of this in-vitro study was to determine the optimal pH at which maximum diffusion of lidocaine occurs across the ETT cuff. Fifteen 8.0 mm ID Portex ETT's were divided into three groups. In each group, the cuffs were filled with 6ml of 2% lidocaine buffered to a pH of 7.4 (Group I), 7.6 (Group II) and 7.8 (Group III). They were then immersed in 20ml distilled water in a water bath set at 38 0 C. The lidocaine diffused was measured using high performance liquid chromatography every half hour interval for up to five hours. There was a significant increase in the onset of diffusion in Group II compared to Groups I and III (P< 0.0001), but the minimum concentration of lidocaine (C m , 155µg.ml -1 ) that is required for blocking the cough receptors was obtained across the ETT cuff by all the three groups at 90 minutes (P >0.05). At 300 minutes, maximum diffusion occurred in both the Groups I and II, which was significantly higher compared to Group III (P <0.05). In spite of the above findings, the present study concluded lidocaine buffered to a pH of 7.4 as the optimal pH for the practical reason that solution in Group I was non-precipitating in nature and hence both filling as well as withdrawing the solution from the cuff was easier in this group, unlike that happened in the Groups II and III.

Three hundred sixty six adult patients scheduled for major abdominal surgery were randomized to receive either general anaesthesia with postoperative parenteral analgesia (Group GA, n=187) or combined general and epidural anaesthesia with postoperative epidural analgesia (Group CEGA, n=179). Aim of the study was to determine whether epidural anaesthesia and analgesia could reduce the incidence of death and major post-operative complications. Overall there was no significant difference in the incidence of mortality and major morbidity between the two groups except that the respiratory complications were significantly reduced in CEGA group (P<0.05). 11 (5.88%)& 7 (3.9%) patients died in the groups GA and CEGA respectively during hospital stay (P>0.05). Pain relief was signifi­cantly better in CEGA group with cumulative pain scores being less in CEGA group (P<0.001). Mean time of ileus was slightly shorter in CEGA group but time of first oral intake& bowel movement as well as length of hospital stay was same in two groups. It was concluded that although the incidence of mortality and all the major morbidities were not reduced by epidural anaesthesia& analgesia, the better pain control and significant reduction in respiratory complications justify the use of epidural analgesia in patients who are expected to have severe pain& may develop postoperative respiratory complications.

Comparison of Sniffing Position and Simple Head Extension for Visualization of Glottis During Direct Laryngoscopy

p. 546

Suresh Kumar Singhal, Naveen Malhotra, Sabhayata Sharma

The prospective randomized study comprised of 200 patients in the age group of 20 to 60 years, belonging to ASA physical status grade I or II, undergoing elective surgery under general anaesthesia with tracheal intubation. The aim was to compare sniffing position with simple head extension for visualization of glottis during direct laryngos­copy and ease of tracheal intubation. All the patients were randomly divided in two groups of 100 each: Group A (sniffing position) and Group B (simple head extension). Direct laryngoscopy was done using Macintosh laryngo­scope (size 3 blade). Glottic visualization during laryngoscopy was assessed using modified Cormack and Lehane classification. After laryngoscopy, tracheal intubation was performed and intubation difficulty score (IDS) recorded. Both groups were comparable regarding glottic visualization (P>0.05). All intubation difficulty score variables (N 1 to N 7 ) were comparable in the two groups except N 3 variable, which was significantly higher (P<0.05) in simple head extension position. Total IDS was significantly better in sniffing position than simple head extension position (P<0.05). To conclude, glottis visualization and intubation difficulty score are better in sniffing position as compared to simple head extension. It is too early to abandon this gold standard (sniffing position) for direct laryngoscopy and tracheal intubation.

Evaluation of Post Succinylcholine Myalgia and Intubation Conditions with Rocuronium Pretreatment: A Comparison with Vecuronium

p. 551

V Abraham, Arti Raj Kumar, L Afzal

We have studied 120 adult patients in the age group of 20-40 years belonging to ASA I or II. Patients were divided into two groups of 60 patients each, taking alternate patient for each group. Group R patients were given rocuronium 0.06mg.kg -1 and Group V patients were given vecuronium 0.01 mg.kg -1 intravenously 60 seconds before the administration of thiopentone followed by succinylcholine. Both groups did not have statistically significant myal­gia on the 1 st post-operative day. On the 3rd postoperative day 3 patients in vecuronium group had moderate myalgia. There was no statistically significant rise in serum potassium, creatinine phosphokinase and urine myoglobin in both the two groups. Rocuronium provides better intubating conditions and effective precurarization within short interval.

The efficacy of 0.25% bupivacaine as a pre-emptive analgesic agent was evaluated in a prospective case control study - a group of patients undergoing elective orthognathic surgery against a matched control group. Bupivacaine was administered as a series of nerve blocks prior to the incision for the surgery. Outcome variables measured were postoperative pain by Visual Analogue Scale (VAS) score, need and amount of rescue analgesics and the incidence of known complications associated with these agents. The VAS score was significantly lower in the group receiving pre-emptive analgesia for upto 40 hours postoperatively, (P<0.05). The amount of rescue analgesics administered and the incidence of complications attributed were less in study group than that of the control group, (P>0.05). Bupivacaine can be used for pre-emptive analgesia in oral and maxillofacial surgery.

We report a case of a 50-year-old man, a known case of hepatitis C virus cirrhosis, who was presented for cadaveric orthotopic liver transplantation. There was severe intraoperative haemorrhage requiring massive transfusion of blood and blood products. During anhepatic phase the supply of our blood bank got exhausted. So we had to replace the ongoing blood loss with volume-expanders for approximately one hour. Patient tolerated haemodilution intraoperatively to the extent of haemoglobin 1.2 g.dl. -1

Congenital hyperinsulinism as seen in nesidioblastosis is the most common cause of non transient neonatal hypoglycaemia. The prime concern in nesidioblastosis is the prevention of dangerous hypoglycaemia which can lead to coma, brain damage or mental retardation. In this report we describe the presentation and perioperative course of a case of nesidioblastosis in a newborn who had persistent hypoglycaemia with convulsions in spite of high concen­trations of dextrose infusion. As sugars were low in spite of medical management, 95% pancreatectomy was done and the baby was discharged following discontinuation of intravenous fluids and starting breast feeds.

Successful Resuscitation in Accidental Complete Transection of Superior Vena Cava During Right Pleuropneumonectomy

p. 569

Rajashree Agaskar, Jyotsna Goswami, Shobhit Bartarya

This is a case report of complete transection of superior vena cava (SVC) during right pleuropn­eumonectomy leading to circulatory collapse and loss of venous access. Access was reestablished by imm­ediate cannulation of saphenous vein in the lower extremity. The patient was resuscitated with intravenous (IV) vasopressin followed by volume replacement. The patient tolerated 40 min of simple SVC clamping in spite of associated severe hypotension.

We report a case of von Willebrand (vWD) disease and highlight the relevance of this condition to the perianaesthetic management.A 23-year-old female, known case of vWD diagnosed at 3 years of age, was posted for laparoscopic ovarian cystectomy. Pre-induction, patient was transfused with cryoprecipitate 10units. Standard tech­nique of anaesthesia was followed with intraoperative cryoprecipitate administration. Surgery was uneventful with adequate hemostasis. Post-operatively analgesia was maintained with morphine patient controlled analgesia(PCA). All intra-muscular injections were avoided. She was transfused with cryoprecipitate/ fresh frozen plasma(FFP) till 5th day and injection tranexamic acid was administered. Postoperative serum coagulation studies were within normal limits.
Patients with vWD do not carry an increased operative risk during elective procedures if appropriate prophylac­tic and corrective therapy is administered. Although the administration of cryoprecipitate and other blood products has traditionally been the cornerstone of treatment for vWD, the recent development of desmopressin(DDAVP) for clinical use may provide an effective alternative to replacement therapy with blood products. Further laparaoscopic procedures, taking care during ryle's tube and foley's catheter insertion, in such patients are the safer alternative for all kind of gynecologic surgeries.

Osteogenesis imperfecta, an inherited disease of connective tissue, is associated with anatomic and physiologic abnormalities which make any form of anaesthesia a challenging task for the anaesthesiologist. We report a case of Osteogenesis imperfecta type -IV with severe anatomic deformities, who underwent replacement nailing procedure for periprosthetic fracture of shaft femur under general anaesthesia. We used a proseal LMA in the case, patient suffered a posterior dislocation of right shoulder on repositioning at the end of the surgery.

Epidural anaesthesia with catheter is very useful technique in modern anaesthesia armamentarium. It is safe, flexible and useful for postoperative analgesia and thus cost effective technique. However, if quality of component(s) (epidural catheter) is poor, it may result in higher incidence of technical failure and inconvenience to operator and harm to patients. We have reported few incidences where the epidural catheter was of poor quality. Our suggestion is that we should use only quality products although the cost may be marginally high but they are more cost effective and safe.

Lung Volume Reduction Surgery (LVRS) has become an accepted modality for chronic pulmonary emphy­sema. Bilateral involve excision of emphysematous alveoli, which results in a 20% to 30% reduction in the volume of each lung. The goal of LVRS is to improve the respiratory mechanics in severe emphysema by re-expanding func­tional lung tissue that has been compressed by over-distended emphysematous alveoli, thus restoring diaphragmatic mobility and improving the bellows function of the chest wall structures. Anaesthesia for LVRS is a significant challenge to the anaesthetist as a result of high risk patient population and the nature of surgery. Management requires good understanding of the pathophysiology of the disease and surgical procedure. Close co-ordination be­tween the anaesthetist, surgeon and other support staff are of paramount importance.

There is a well known association of rheumatoid arthritis with coronary artery disease. We report a 59 year old male patient with rheumatoid arthritis who underwent off pump coronary artery bypass grafting(OPCAB). He had extensive arthritis and contractures involving all major joints. There was restriction of all movements in the neck though mouth opening was adequate. The cannulation of radial and femoral arteries was difficult because of the contractures in the wrist and hip joints. Intubation was difficult and was accomplished with intubating bougie. Post operatively the patient developed plate atelectasis. The various anaesthetic implications of rheumatoid arthritis in OPCAB and their effective management are discussed.

We describe a case of 55-year-old female who had deterioration of respiratory and haemodynamic status after hysterectomy under subarachnoid block. On the second postoperative day she had to be intubated and sustained on ventilatory and inotropic support. The patient had apparently no previous cardio-respiratory-renal or neurological problem. Her CT scan revealed a space occupying intracranial lesion. The etiopathogensis and future management of such patients is discussed after review of current literature.